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The University of North Carolina at Chapel Hill School of Nursing
Nursing 591
Course Syllabus
Nursing Care of Patients with Major Adult Health Problems II
NOTE: Faculty reserves the right to amend the contents of this syllabus. Students will be advised of
any changes in a timely manner. This syllabus may not be reproduced without the permission of the
Course Coordinator and the Program Director.
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Nursing 591 Course Syllabus
Course Title Nursing Care of Patients with Major Adult Health Problems II Semester Spring, summer, or fall Credit 8 credits (3 classroom credits; 5 clinical credits) Prerequisites N354, N364, N371, N472, N477, either N487, N488, or N489 Prerequisites or Co-requisites N470 Day/time/location varies per semester
Problem-based learning, skills review, human patient simulator sessions, and clinical seminars are in addition to scheduled class time.
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COURSE DESCRIPTION
This senior level course focuses on applying critical thinking, clinical decision-making, and evidence-based nursing practice to complex health problems of adults. Unique health needs of older adults are addressed.
COURSE OBJECTIVES By the completion of the course, the student will:
1. Integrate use of nursing process, professional behavior, and evidence-based practice in the delivery of patient-centered, holistic care to adults with complex health problems.
2. Synthesize concepts of caring, critical thinking, and clinical decision-making as foundational in the care of acutely ill adults.
3. Analyze the relationships among disease process, clinical presentation, and nursing management of patients with selected major adult health problems.
4. Apply knowledge of the nursing management of selected, complex adult health problems, incorporating best practice guidelines, across the continuum of care.
5. Integrate knowledge of the needs of older adults into the plan of care.
GRADING AND EVALUATION
Seniors are expected to attend all scheduled exams and classes. Students who are unable to take
exams as scheduled should contact the course coordinator to explore alternative options no later
than 24 hours before the scheduled exam time. Failure to qualify for an excused absence will
result in a grade of 0 for that exam. Examples of excused absences include dire personal or
family emergency, personal grave illness, hospitalization of the student or an immediate family
member or death of an immediate family member. Scheduled events such as interviews, travel
plans, weddings, and non-emergent health care services are not considered excused absences. In
the event of an unusual circumstance, the Course Coordinator and the Director of Undergraduate
Programs will review and approve an excused absence.
Quizzes will be given during the semester. Missed quizzes cannot be made up.
All course assignments are due at the time specified by clinical faculty or course syllabus. For
required course assignments other than exams, quizzes, and clinical, the student must arrange for
extensions directly with the clinical faculty or course coordinator no later than 24 hours before
the assignment is due.
Late assignments
Students who submit assignments after the due date without prior faculty approval will have 1%
deducted from their final course grade for each day the assignment is late. Assignments include
all work including weekly clinical and clinical reflection worksheets.
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Grading criteria for written assignments, clinical activities, and examinations
Clinical Activities
Clinical performance pass/fail
Basic EKG Tutorial pass/ (requires 80%)
PBL pass/fail
Human patient simulator session (STAN) pass
ATI Pharmacology 2.0
Non-Proctored Assessment pass/ (requires 80%)
Written Assignments Points
Critical incident paper 100
Article reviews (2) 100
Discussion forum (2) 50
Exams Points
Quizzes 50
Exam I 200
Exam II 200
Final exam 300
Total points 1000
Conversion scale for percentage/letter grades
A = 95-100
A-= 92-94
B+= 89-91
B = 86-88
B-= 83-85
C+=80-82
C = 77-79
C-= 74-76
D+= 71-73
D = 65-70
F =<65
NOTE: Students much achieve an average of 74% on the three exams in order to pass the
course. If a student does not achieve the 74% average, the final grade assigned will be the
average of the three exams, excluding the other grade components.
ATI Testing
To assist in learning the course content and preparing for the NCLEX examination, students will
be given the ATI Adult Medical-Surgical Nursing review book. At the end of the course,
students will take the ATI adult medical-surgical nursing content mastery assessment. The test
must be completed to pass the course. This examination will include content from N591 and
from N364. Students are strongly encouraged to access the ATI website: www.atitesting.com for
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opportunities to take ongoing assessment tests that will also assist them in their learning and
preparation for licensure.
For the content mastery assessment students may earn bonus points that will be added to the final
exam grade as follows:
Students meeting proficiency level 3 – 2 points
Students meeting proficiency level 2 – 1 point
Students must achieve an average of 74% on the three exams before any bonus points are added.
In addition, students are required to take the ATI Pharmacology 2.0 Non Proctored Assessment.
Students must pass this examination with a score of 80%. A copy of the results must be
submitted to the course coordinator as directed in the course schedule.
Evaluation of clinical performance
Clinical is divided into 2 rotations. Each rotation involves 96 hours of focused learning activities
by the senior on the clinical unit (separate from clinical preparation), clinical orientation, weekly
preparation activities, problem-based learning seminar activities, and case studies using the
human patient simulator. Evaluation of clinical performance in N591 will be determined by
faculty evaluation of senior performance.
A senior who fails either clinical rotation will fail clinical and Nursing 591.
Data for clinical evaluation will be gathered from performance in clinical practice, written work,
group activities, discussion forum activities and verbal interaction. Clinical evaluation
information will be shared periodically with the senior
Student Responsibilities
Students are expected to attend all clinical experiences except when ill. If absence is
unavoidable, the student is responsible for notifying faculty, the clinical teacher, and the clinical
unit and arranging make-up time with the clinical teacher. A student who misses 16 hours of
clinical must seek immediate guidance from clinical faculty. Students can review the School of
Nursing attendance policy in the Undergraduate Handbook available online at http://nursing.unc.edu/current/student-handbook/CCM3_030197
EMAIL ADDRESSES The School of Nursing requires students to use their UNC email addresses as their “official email address” registered with the University. No other email address will be used to communicate with students. Students must regularly check their official UNC email address to ensure receipt of all course, School of Nursing and University communications. REQUIRED TEXTBOOK Lewis S, Heitkemper, M.M., Dirksen, S.R., O’Brien, P.G., & Bucher, L. (2007). Medical-Surgical Nursing - Assessment and Management of Clinical Problems (7
th ed.). St. Louis:
Mosby.
RECOMMENDED TEXTBOOK
American Psychological Association. (2001). Publication manual of the American
Psychological Association (6th
ed.). Washington, DC: Author.
Helpful website
For APA: http://owl.english.purdue.edu/handouts/research/r_apa.html http://flash1r.apa.org/apastyle/basics/index.htm
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COURSE ASSIGNMENTS
Guidelines for completing the following can be found under the icons Assignments and Clinical
Component on the course website.
Article Reviews
Students are expected to expand their use of resources for evidence-based practice
beyond the required text, and explore nursing and related literature to improve their
understanding and application of advanced interventions. Use of refereed professional
nursing literature to guide interventions will be reflected in the submission of two article
critiques that have direct application to planning, implementing and evaluating care of a
patient the student cared for in clinical. Due dates with be divulged by clinical faculty.
Critical Incident Paper
In order to foster critical thinking about nursing problems, and an investigative approach
to understanding complexities of nursing practice, students are require to write a “Critical
Incident Paper.” The purpose of this paper is to provide the student with an opportunity
to demonstrate his/her insight and learning resulting from a clinical experience that was
particularly important for the student’s learning. The incident does not have to be
“critical” for the client, but it does have to reflect a client problem that is within the realm
of nursing. It cannot be a medical or other problem that is outside the legal scope of
nursing intervention.
The due date for the critical incident paper is October 29, 2010 by 5:00 pm.
Two copies of critical incident papers are to be submitted to first rotation clinical
faculty.
EVALUATION: 10% of course grade. To pass the clinical component of Nursing 591, the senior
must achieve a grade of 74 or greater on the critical incident paper. The senior whose paper
does not meet the minimum of 74 will be given the opportunity to rewrite the paper. The senior is
responsible for negotiating a date for submission of the rewritten critical incident paper with the
clinical faculty. The maximum grade that can be achieved with a rewritten paper is 74.
Problem-based Learning
Problem-based learning (PBL) is a method of learning in which students use clinical
cases to refine problem-solving skills and acquire nursing knowledge related to the
Nursing 591 content areas. With PBL, students are empowered with the responsibility
for their own learning, using small group work to support and learn from each other.
Through PBL, students are challenged to address group communication and division of
workload responsibilities in part as preparation for dealing with real-life work issues.
PBL also assists the student in refining his/her plan for continued inquiry by providing
practice in identifying and critiquing sources of nursing knowledge for their relevance,
efficiency, depth and accuracy.
STAN sessions
STAN (human patient simulator) sessions encourage seniors to refine their focused
assessment and problem solving skills and increase their critical thinking abilities in the
application of theory to practice.
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Clinical Seminar
The purpose of the clinical seminar is to provide seniors with the opportunity to meet
with their peers, analyze complex clinical situations and share knowledge obtained
through their clinical preparation and clinical experiences.
Discussion Forums
The discussion board fosters individual reflection on and identification of significant
aspects of clinical learning as well as thoughtful communication of that learning within
the clinical group. Sharing clinical experiences enables students to learn from each other
and provides peer support for professional development.
Skills Lab
Students participate in a skills review prior to beginning clinical. Skills lab assistance is
available throughout the semester via individual appointment based on the senior’s
particular interests or specific needs
HONOR CODE (http://nursing.unc.edu/current/student-handbook/CCM3_030203) The Honor Code and the Campus Code, embodying the ideals
of academic honesty, integrity, and responsible citizenship,
have for over 100 years governed the performance of all
academic work and student conduct at the University.
Acceptance by a student of enrollment in the University
presupposes a commitment to the principles embodied in these
codes and a respect for this most significant University
tradition. Your participation in this course comes with the
expectation that your work will be completed in full observance
of the Honor Code. Academic dishonesty in any form is
unacceptable, because any breach in academic integrity,
however small, strikes destructively at the University's life and
work. If you have any questions about your responsibility or the
responsibility of faculty members under the Honor Code, please
consult with someone in either the Office of the Student
Attorney General (telephone: 919-966-4084) or the Office of
the Dean of Students (telephone: 919-966-4042). For
additional information about the honor code, please also refer to
the University website. The Information for Students and
Plagiarism sections are especially helpful.
Religious Observances The School of Nursing recognizes and respects that many
religions have days of the year and celebrations they
honor. In order to assure reasonable accommodations and
appropriate alternative assignments, when a student in a
non-clinical course needs to miss classes, exams, and/or
written assignments due to the observance of a religious
holiday, he/she must notify the course coordinator in
writing about the conflict at least three weeks before the
beginning of the religious observance.
To view the entire School of Nursing policy regarding
religious holiday observances go to: http://nursing.unc.edu/current/student-handbook/CCM3_030197
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DISABILITY SERVICES (http://disabilityservices.unc.edu
If you have a disability
(http://nursing.unc.edu/current/student-
handbook/CCM3_030195) that requires an accommodation
in this class, you need to communicate those needs to the
Department of Disability Services (962-8300) or Learning
Disability Services (962-7227)
(http://www.unc.edu/depts/lds).
CLINICAL REGULATIONS AND COMPLIANCE POLICIES
(http://nursing.unc.edu/current/student-handbook/CCM3_030306)
Students must maintain full compliance with all renewable requirements throughout their tenure
with the School. Student compliance is expected regardless of the type of course(s) taken in a
particular academic term. Failure to attain or maintain compliance with the School’s health and
safety requirements may result in the student being disenrolled.
Other Important Policies:
Professional Attire (http://nursing.unc.edu/current/student-handbook/CCM3_030314)
Travel Regulations (http://nursing.unc.edu/current/student-handbook/CCM3_030315)
Inclement Weather Policy (http://nursing.unc.edu/current/student-handbook/CCM3_030313
For information about cancellation/delays with lectures or optional classroom activities please
check the Blackboard course site. For information about possible cancellations/delays with
Nursing 591 clinical, please check with your clinical faculty.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) In this course, all patient information must be treated in accordance with HIPAA requirements in
terms of clinical experiences, case studies, or other course requirements that might be met using
patient information. No patient identifiers may be used or disclosed as you meet course or
research requirements. Email should not used for sending confidential patient information.
PDAs and laptop computers, if used for patient information and clinical experiences, should be
afforded the same level of protection as written information and must employ power-on
passwords and an automatic logoff. If you use paper notes which contain protected health
information for your clinical experiences, you are responsible for using minimal identifiers,
maintaining appropriate security of your notes, and shredding any patient-related information at
the end of this course. If in doubt about how to handle any patient information, please check
with course faculty.
BLOODBORNE PATHOGEN EXPOSURE
The senior who experiences a potential bloodborne pathogen exposure in clinical is to do the
following:
Notify the clinical teacher and clinical faculty right away. The student should NOT
evaluate own risk – determination of potential exposure and treatment is done by Student
Health Services. It is the student’s responsibility to report. Follow the agency’s
needlestick exposure protocol. Call SHS Needlestick Hotline (919)966-6573. Leave the
clinical agency (after notifying the agency staff and your clinical faculty) and
immediately report to UNC-Student Health Services SHS). In cases where you are
unable to report to campus within two hours because of driving conditions, your clinical
faculty will tell you where to report for emergency follow-up care. Once you have
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received emergency follow-up care, you should report to SHS as soon as possible for
further follow-up.
Clinical Faculty and Clinical Teacher Responsibilities
Nursing 591 Clinical Faculty Responsibilities
All students will have face-to-face contact with their faculty within the first two weeks of
clinical. During this time, clinical faculty will meet with the preceptors to determine the best
alternate means of communication (i.e. email, telephone) for days when face to face
communication is not possible. Clinical faculty are required to meet face-to-face with students
and preceptors a minimum of 3 (or 4) times during the rotation but have the option of meeting
more often if issues arise.
Facilitate the clinical application of course content and critical thinking by seniors through the
design of clinical experiences.
Assist the senior to apply course content in clinical, engage in critical thinking with the
integration of theory and research into practice, examine their professional practice and that of
peers, and evaluate standards of care in the clinical area.
Assist the senior in examining and refining his/her caring behaviors so as to be sensitive to the
needs of clients and families who reflect a richness of diversity and uniqueness.
Serve as a colleague with the senior as the senior considers plans for career development and job
exploration.
In conjunction with the course coordinator and clinical teachers, ensure the integrity of senior
clinical experiences with regard to Nursing 591 objectives and terminal undergraduate program
objectives.
Collaborate with nursing management with a shared goal of optimal care of clients, support of
the nursing unit, and quality educational experiences for seniors as issues arise regarding seniors,
staff, or clients.
Develop a relationship with the clinical agency and engage in activities to promote the clinical
faculty’s expertise in a clinical content area and maintain a current awareness of professional,
agency, and health care issues.
Serve as a colleague and resource to members of the nursing unit, and engage in mutually
negotiated agency-based activities, such as research utilization studies, client education projects,
or staff development activities.
Communicate on a regular basis with clinical teachers, unit managers and seniors.
Lead regularly scheduled evaluations of senior performance.
Work with clinical teachers to promote their development as preceptors.
Serve as a mentor for the clinical teacher to promote his/her professional growth.
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Nursing 591 Clinical Teacher Responsibilities
Accept a 1:1 professional relationship with a senior for the clinical rotation.
Provide an average of 16 hours per week of clinical experience for students.
Support the senior as a learner throughout the clinical experience; advocate for the senior in the
learner role.
Foster the senior’s professional behavior in interactions with clients, family, and other members
of the health care team.
Serve as a role model in all aspects of professional nursing related to the nurse’s job description.
Accept responsibility for the safety and well-being of the senior’s clients including adequate
supervision of psychomotor skills until safety and competency are demonstrated.
Provide guidance for additional clinical experiences, prerequisite learning activities, or
alternative, interdisciplinary, learning activities, which contribute to the senior’s acquisition of
essential content and skills. Evaluate and countersign student documentation.
Provide the senior and clinical faculty with regular feedback about the senior’s performance in
meeting the course objectives, senior’s personal objectives, and unit competency standards of
professional nursing practice.
Provide evaluative data to the clinical faculty about the senior’s performance with regard to the
course objectives and participate in end of rotation evaluation (via written or verbal feedback).
Call or page the faculty for any questions or concerns regarding student performance.
Participate in clinical teacher development and evaluative activities.
Nursing 591 Plan for Students Having Problems in Clinical
The following guidelines are to be used if a student is having problems in clinical:
Students are encouraged to first discuss any concerns or problems in clinical directly with
their clinical teacher and clinical faculty as soon as possible. The course coordinator and
Director of the Undergraduate Program are additional resources that are available to the student
to discuss problems and concerns in clinical.
The nature of problems in clinical will dictate the course of action. Safety issues call for
immediate action and remediation. The clinical agency’s policy regarding actions by staff nurses
that require completion of a variance report is to apply to the student’s behavior. The completion
of the variance report should be done jointly by the student and clinical teacher as a learning
activity (versus punitive action). The student must notify the clinical faculty immediately if
such a safety issue arises. The course coordinator and Director of the Undergraduate Program
are to be notified of all episodes in which variance reports are required because of a student’s
actions/inactions.
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The identification of patterns of student behavior that are inconsistent with standards of
care may take longer to identify and require more complex plans for remediation. The student
who is considered unsafe to practice by the clinical teacher/clinical faculty within the course
objectives and given clinical setting may be immediately removed from clinical. Based on the
judgment of the clinical faculty as to the potential seriousness of the unsafe behavior, a grade of
“fail” may be awarded for the clinical component of the course.
The primary responsibility for a plan of remediation is with the UNC-CH School of
Nursing faculty. The student should receive direct verbal feedback from the clinical faculty at
the earliest possible time following student demonstration of unsafe behaviors or failure to
demonstrate behaviors consistent with the Nursing 591 course objectives. This should be
followed, as soon as possible, by a three-way conference involving the student, clinical faculty,
and course coordinator. The purpose of this conference is to discuss and document the nature of
the problem including a clear written description of the behaviors (or lack thereof) that make up
the problem, and to outline a plan of remediation which describes the behaviors to be
implemented by the student and clinical faculty. All participants in the three-way conference are
to sign and receive a copy of the documentation.
The remediation plan will become part of the course evaluation, and weekly progress
reports will be shared among the student, clinical faculty, and clinical teacher. The clinical
faculty will keep the course coordinator informed as to the student’s progress. UNC faculty will
take primary responsibility for requesting a conference to discuss student problems and progress.
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Overview of Course Content
Problems related to altered sensory input
Burns
Problems related to immunologic function
Human immunodeficiency virus infection
Problems of ingestion, digestion, absorption, and elimination
Upper gastrointestinal problems
Lower gastrointestinal problems
Liver, pancreas and biliary tract problems
Problems of urinary function
Acute renal failure and chronic kidney disease
Common Urological Issues
Problems related to regulatory and reproductive mechanisms
Female and male reproductive problems
Endocrine problems
Problems related to movement and coordination
Acute intracranial problems
Stroke
Chronic neurologic problems
Spinal cord injury
Musculoskeletal problems
Problems of oxygenation and perfusion
Dysrhythmias
Problems related to oxygenation and transport
Hematological issues
Nursing care in specialized settings
Respiratory failure and acute respiratory distress syndrome, ABG analysis
Shock, systemic inflammatory response syndrome, multiple organ dysfunction
syndrome
Emergency management
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University of North Carolina at Chapel Hill
School of Nursing
Weekly Clinical Focus and Progress Tool
Nursing student: ___________________ Preceptor: _________________ Unit: __________
Complete before each week by establishing your clinical focus either independently or after consultation with
the preceptor. Incorporate clinical focus into selection of patient assignment/care activities.
Observations should be completed at the end of the week by both student and preceptor and could include:
Completion of clinical foci; organizations skills, ability to set priorities; communication skills; critical
thinking and caring skills; ability to assess, plan, implement and evaluate patient care; use of rationale for
care; documentation skills.
Clinical Focus Student’s Self Evaluation Preceptor’s Observations
Week 1-Date:
Week 2-Date:
Week 3-Date:
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Week4-Date:
Week 5-Date:
Make-Up Week Date:
15
Weekly Clinical Reflection
There is much more you do each week with your preceptor than what occurs when clinical
faculty do site visits. This weekly reflection provides you with the opportunity to discuss things
that were critical in your learning. You may choose to talk about a learning moment or patient
situation that struck a nerve, or something that made you bring the whole patient picture
together. (ie incorporating labs/diagnostics). This opens up an additional channel of
communication between you and your clinical faculty member.
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UNC CHAPEL HILL SCHOOL OF NURSING CLINICAL EVALUATION TOOL
(4/27/10)_
This clinical evaluation tool consists of nine essential competencies with specific performance
criteria. The nine competencies were drawn from: terminal outcome objectives for the BSN
program at UNC Chapel Hill School of Nursing, The Essentials of Baccalaureate Education for
Professional Nursing Practice (AACN, 2008) and Quality and Safety Education in Nursing
(Cronenwett et al., 2007). The performance criteria for each competency include cognitive,
affective, and psychomotor domains of learning and provide a complete evaluation of an
individual student’s clinical performance. The use of this clinical evaluation tool makes it
possible to see the student’s development over time as he/she progresses through the specific
course, as well as through the nursing curriculum. It also provides standard measures for student,
course, and program evaluation.
Directions
Required Use: This clinical evaluation tool is designed for use in each clinical course. A formal
evaluation is completed and shared with the student at mid-rotation and at the conclusion of the
rotation.
Suggested Use: The tool can also be used at other times during the rotation and can serve as the
basis for a learning contract. Students may be asked to complete a weekly self evaluation based
on the competencies, addressing at least two competencies each week until all have been
adequately addressed.
Instructions: Faculty will rate students on each of nine competencies using the designated rating
scale, considering the quality of the performance (Almost Never Exhibits to Almost Always
Exhibits) and the amount of guidance required (Almost Always Requires to Almost Never
Requires). Referring to the scale below, as students improve in accuracy, safety, and efficiency,
it is expected that they will require less guidance. To determine the rating for each competency,
rate the student using the 0-4 scale on all performance criteria. If the student has not had
opportunity or the criterion is not applicable, indicate “not applicable” (NA). Total the score for
the competency and divide by the number of criteria scored to get an average score for each
competency.
For the final clinical evaluation, faculty should write summary comments and document
recommendations for further development/improvement.
Safety:
The student is required to practice professional nursing safely in specific patient-centered situations with clinical
supervision. “Client” is defined as the recipient of professional nursing services and may be an individual, family,
or group. Safe behavior is defined as behavior which does not place the client or self and other
professional staff at risk of physical and/or psychosocial harm. The student is subject to receiving an F in the
course and to being dismissed from the program if safe behavior is not consistently demonstrated.
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The Rating Scale
Self-Directed (4)
Almost Never Requires (<10% of the time)
Direction
guidance
monitoring
support
Almost Always Exhibits (>90% of the time)
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
Supervised (3)
Occasionally Requires (25% of the time)
direction
guidance
monitoring
support
Very Often Exhibits (75% of the time)
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
Assisted (2)
Often Requires (50% of the time)
direction
guidance
monitoring
support
Often Exhibits (50% of the time)
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
Novice (1)
Very Often Requires (75% of the time)
direction
guidance
monitoring
support
Occasionally Exhibits (25% of the time)
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
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Dependent (0)
Almost Always Requires (>90% of the time)
direction
guidance
monitoring
support
Almost Never Exhibits (<10% of the time)
a focus on the client or system
accuracy, safety, and skillfulness
assertiveness and initiative
efficiency and organization
an eagerness to learn
From: Holaday, S., & Buckley, K. (2008). A standardized clinical evaluation tool-kit: Improving nursing education and practice. In M. H. Oermann & K. T. Heinrich (Eds.), Annual Review of Nursing Education, Vol. 6. New York: Springer Publishing.
Expected Levels of Performance:
For the final evaluation students must achieve the minimal expected level of performance for
each competency in order to pass the course and progress in the program.
Level Minimal
Expected
Performance
Minimum
Score
Upon completion of:
I Novice -
Assisted
1.5 N364
II Assisted 2.0 1 or 2 specialty courses (N470, N472, N477, N479)
III Assisted –
Supervised
2.5 3 or 4 specialty courses (N470, N472, N477, N479)
IV Supervised –
Self-directed
3.0 N591
COMPETENCIES
1. Demonstrates professional behaviors Rating:______
Performance Criteria:
a. Follows university, school, and agency policies
b. Practices within the legal and ethical frameworks of nursing
c. Assumes accountability for own actions and practices
d. Treats all individuals with dignity/respect
e. Demonstrates cultural sensitivity
f. Protects client rights (privacy, autonomy, confidentiality)
g. Demonstrates initiative in seeking learning opportunities and resources
h. Analyzes personal strengths and limitations in providing care
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i. Incorporates constructive feedback for performance improvement
j. Maintains professional appearance
k. Maintains professional attitude
l. Maintains professional behavior
m. Prepares for clinical practice
n. Identifies situations in which assistance is needed OR Appropriately seeks assistance
Comments:
2. Collects and analyzes comprehensive client data Rating:______
Performance Criteria:
a. Determines relevant information needed
b. Identifies appropriate sources for data collection
c. Uses correct techniques for assessment
d. Interprets laboratory/diagnostic test results
e. Incorporates data from client, family/support persons and health care team members
Comments:
3. Plans appropriate client care Rating:______
Performance Criteria:
a. Develops plan of care based on analysis of assessment data.
b. Accurately determines priorities for care
c. Communicates priorities and rationale for decisions to instructor
d. Considers needs/preferences of the client in planning care
e. Establishes realistic goals/expected outcomes
f. Identifies appropriate resources to inform care planning
Comments:
4. Provides safe client-centered care Rating:______
Performance Criteria:
a. Plans and implements evidence-based interventions that are congruent with
assessment data
b. Considers client needs and preferences in providing care.
c. Performs nursing skills and therapeutic procedures safely and competently
d. Follows principles of infection control
e. Follows procedures for medication administration
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f. Recognizes own limitations related to nursing skills or technologies and takes
appropriate steps for improvement
g. Takes appropriate steps to improve nursing skills and use of technologies.
h. Creates a safe environment for client care
i. Demonstrates flexibility in adapting to changing client care situations.
j. Reports abnormal data and changes in client condition to instructor or appropriate health
team member
k. Honors and promotes the rights of clients and others by acting on their behalf and in their best
interest
Comments:
5. Engages in systematic and ongoing evaluation of the plan of care Rating:___
Performance Criteria:
b. Evaluates nursing interventions based on goals/expected outcomes
c. Analyzes client data for accuracy and completeness
d. Revises plan of care based on evaluation and consultation.
e. Involves client, significant others, and health team members in evaluation process as relevant
Comments:
6. Applies knowledge relevant to client care Rating:___
Performance Criteria:
a. Demonstrates initiative to obtain needed knowledge.
b. Evaluates sources of data for appropriateness, usefulness, and accuracy.
c. Integrates theory from nursing, natural and social sciences to enhance client care
d. Relates pathophysiology and epidemiology of disease(s) to clients’ assessment findings,
medications, laboratory and diagnostic test results, medical and nursing interventions.
e. Integrates concepts of health promotion and disease prevention into client care
f. Identifies issues/problems in nursing practice that need to be improved.
g. Evaluates nursing practices based on current research evidence.
Comments:
7. Communicates effectively Rating:___
Performance Criteria:
a. Produces clear, relevant, organized, and thorough writing
b. Exhibits timely, legally accurate, and appropriate documentation.
c. Communicates therapeutically with clients utilizing verbal and nonverbal skills
d. Listens attentively and respectfully to others.
e. Is actively involved in team building, fostering collegiality, and encouraging cooperation.
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f. Contributes insight and helpful information to the health care team/group conferences
Comments:
8. Uses teaching-learning process when providing individualized client/family/group
education Rating:___
Performance Criteria:
a. Assesses learning needs of clients, families, and groups.
b. Assesses readiness for and barriers to learning.
c. Considers appropriate client characteristics in teaching (e.g., culture, age, developmental level, and
educational level)
d. Develops an appropriate teaching plan for learner needs.
e. Specifies reasonable and appropriate outcome measures.
f. Utilizes appropriate principles of teaching/learning when implementing a teaching plan.
g. Evaluates learner outcomes, provides feedback, and revises teaching plan as needed.
Comments:
9. Exhibits caring to facilitate physical, mental, and spiritual health Rating:___
Performance Criteria:
a. Demonstrates sensitivity to cultural, moral, spiritual, and ethical beliefs of clients, families, peers, health
care team members, and others.
b. Recognizes barriers to care such as socioeconomic factors, environmental factors, and support systems.
c. Protects the client’s safety and privacy, and preserves human dignity while providing care.
d. Encourages family and/or significant others’ participation in care as appropriate.
e. Assists clients with coping and adaptation strategies.
Comments:
Final Evaluation:
Comments:
Recommendations for further development/improvement:
22
References
American Association of Colleges of Nursing. (2008). The Essentials of Baccalaureate Education for Professional
Nursing Practice. Washington DC: AACN.
Cronenwett, L., Sherwood, G., Barnsteiner J., Disch, J., Johnson, J., Mitchell, P., Sullivan, D., Warren, J. (2007).
Quality and safety education for nurses. Nursing Outlook, 55(3)122-131.
Holaday, S., & Buckley, K. (2008). A standardized clinical evaluation tool-kit: Improving nursing education and
practice. In M. H. Oermann & K. T. Heinrich (Eds.), Annual Review of Nursing Education, Vol. 6. New
York: Springer Publishing.
